Crash Course, How Boeing's Managerial Revolution Caused the 737 Max Disaster

This contains some tidbits I've not previously read elsewhere, including this: Boeing agreed to rebate Southwest $1 million for every MAX it bought, if the FAA required level-D simulator training for the carrier’s pilots.

And yet however unlikely that would have been, it had the effect of pressuring all change decisions that could potentially cause such a requirement. It actually brings an airline, perhaps not just South West, into the culture that culminated in the ensuing debacle. They are part of the problem.

I also better understand the motive behind why they chose to use only one sensor? Complexity means less likely to keep this feature a secret, literally, from the FAA, from the FOM, from training, from unions, from pilots, and maybe even the airlines. The more complex the system, the more it'll have to account for contradictory inputs, and a likely requirement of an in-cockpit indicator to notify pilots of the contradiction/confusion, and that necessarily leads to pilot training. Ironically, more redundancy in this case would lead to the very think Boeing and at least one airline, were explicitly trying to avoid. And so they did avoid it.

This article mentions US Air 427. The FDR in that case proves the pilots made a mistake, they pulled back on the yoke the entire time, aggravating the stall, making recovery impossible. Of course then as now, Boeing blamed pilots, that much is consistent. What aggravates me is this "3rd world" pilot excuse making b.s. when U.S. pilots have fallen into the exact same trap. Air France 447, one of the pilots was pulling back on the yoke the entire time. This is not a "3rd world" pilot problem. It is not an "airmanship" problem like Langewiesche recently argued. It's really a panic management problem with our lizard brain.

Flights 427, 610, and 302 all start with an airplane defect that then turns the airplane into a saboteur. With perfect information a pilot could have saved those flights, but the fact they didn't have perfect information doesn't mean their mistake is the biggest mistake. If a human being took the action these airplanes took, we would call them malevolent, and had everyone survived, the instigating person would be imprisoned.

I find it odd that Professional Engineers bear greater professional and career responsibility and risk than managers, who wield more decision-making power. There is no analogous mechanism to strip a manager of their Professional Manager certification like can theoretically happen to P.E.'s, yet they are the ones who institute the systems, processes and cultures that everyone else must abide by.

This appears to be a scaling failure in how we build organizational and political power abstractions.

The 737 MAX has new powerful engines and are placed more forward on the wing. This changes the handling characteristics and is most noticeable during takeoffs as the nose tends to rise more readily. The simple solution is to require an hour or two of simulator time to train pilots on the new handling characteristics. In hindsight, using MCAS to account for this new behavior was the wrong choice. I know simulator time is expensive and so on, but this would have been the logical thing to do. Besides I hear the MCAS software was not developed by Boeing but had been outsourced.